Provider Demographics
NPI:1003175365
Name:MITICHE, NORA D (NP)
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:D
Last Name:MITICHE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 S SCATTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-4235
Practice Address - Country:US
Practice Address - Phone:765-644-5025
Practice Address - Fax:765-643-4534
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004009A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01390902OtherMEDICARE RR PTAN
IN201074320Medicaid
IN201074320Medicaid